Form F-16029 "Foodshare Wisconsin Repayment Agreement" - Wisconsin

What Is Form F-16029?

This is a legal form that was released by the Wisconsin Department of Health Services - a government authority operating within Wisconsin. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2008;
  • The latest edition provided by the Wisconsin Department of Health Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form F-16029 by clicking the link below or browse more documents and templates provided by the Wisconsin Department of Health Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form F-16029 "Foodshare Wisconsin Repayment Agreement" - Wisconsin

Download PDF

Fill PDF online

Rate (4.6 / 5) 27 votes
STATE OF WISCONSIN
OP
DEPARTMENT OF HEALTH SERVICES
Division of Health Care Access and Accountability
F-16029 (07/08)
FOODSHARE WISCONSIN REPAYMENT AGREEMENT
Personally identifiable information will be used only for the direct administration of FoodShare Wisconsin.
Case Name
Case Number
Agency Representative Name
Date
Amount Due $
Complete and sign the repayment agreement below and return this agreement no later than
/
/
to:
(Agency Address)
Repayment Terms: You may repay the overissuance by one of the following:
1.
Initial - You may make an initial cash payment to repay all or part of the amount due.
2.
Monthly Payment - You may repay in monthly payments whether your case is open or closed. The minimum monthly payment
must be at least $
. If your financial situation changes, you may request a re-negotiation of the repayment
agreement. If you fail to make the monthly payments and your case is open the State will automatically collect any overissuance
by reducing your FoodShare benefits each month.
3.
Benefits Reduction - If your case is open, you may repay the overissuance by reducing your monthly FoodShare benefits. The
minimum monthly payment must be at least $
.
4.
Voluntary Payment – You can make voluntary payments, in addition to the minimum monthly payment, using your FoodShare
benefits.
Monthly payments must be at least $10 if the overpayment is due to client or agency error and at least $20 if the overpayment was
due to an Intentional Program Violation. If payments are missed and the debt becomes delinquent, this repayment agreement shall
be null and void and the balance remaining on the overpayment shall be immediately due and owing and the agency will have the
right to take collection actions to recover the entire overpayment.
If this debt becomes delinquent the liable individual(s) may be subject
to additional processing fees.
Supplements: If you owe an overissuance amount and become eligible for a supplemental FoodShare allotment, we will credit the
supplemental FoodShare allotment to the overissuance amount you owe.
REPAYMENT AGREEMENT
Cash repayments may be made electronically online at
https://dwd.wisconsin.gov/epayment/
if you have a checking
account. Please have your PIN available as you will need it to enter it into the electronic payment system.
I AGREE TO REPAY (check one):
1. Initial Payment- In one cash payment in the amount of $
.
2. Monthly Payments - In monthly payments of $
. I understand that if I am currently receiving or if I
receive FoodShare benefits in the future, any outstanding amount may be collected by reducing my FoodShare benefits.
3. Benefit Reduction - By reducing my current monthly FoodShare benefits by $
. I understand that if my
FoodShare benefits are terminated, any outstanding amount owed must be collected.
4. Voluntary Payments – Of $
FoodShare benefits, in addition to the minimum monthly payment
above.
Participant’s Signature
Date Signed
7CFR 273.18
RETAIN COMPLETED FORM IN CASE RECORD
RESET FORM
STATE OF WISCONSIN
OP
DEPARTMENT OF HEALTH SERVICES
Division of Health Care Access and Accountability
F-16029 (07/08)
FOODSHARE WISCONSIN REPAYMENT AGREEMENT
Personally identifiable information will be used only for the direct administration of FoodShare Wisconsin.
Case Name
Case Number
Agency Representative Name
Date
Amount Due $
Complete and sign the repayment agreement below and return this agreement no later than
/
/
to:
(Agency Address)
Repayment Terms: You may repay the overissuance by one of the following:
1.
Initial - You may make an initial cash payment to repay all or part of the amount due.
2.
Monthly Payment - You may repay in monthly payments whether your case is open or closed. The minimum monthly payment
must be at least $
. If your financial situation changes, you may request a re-negotiation of the repayment
agreement. If you fail to make the monthly payments and your case is open the State will automatically collect any overissuance
by reducing your FoodShare benefits each month.
3.
Benefits Reduction - If your case is open, you may repay the overissuance by reducing your monthly FoodShare benefits. The
minimum monthly payment must be at least $
.
4.
Voluntary Payment – You can make voluntary payments, in addition to the minimum monthly payment, using your FoodShare
benefits.
Monthly payments must be at least $10 if the overpayment is due to client or agency error and at least $20 if the overpayment was
due to an Intentional Program Violation. If payments are missed and the debt becomes delinquent, this repayment agreement shall
be null and void and the balance remaining on the overpayment shall be immediately due and owing and the agency will have the
right to take collection actions to recover the entire overpayment.
If this debt becomes delinquent the liable individual(s) may be subject
to additional processing fees.
Supplements: If you owe an overissuance amount and become eligible for a supplemental FoodShare allotment, we will credit the
supplemental FoodShare allotment to the overissuance amount you owe.
REPAYMENT AGREEMENT
Cash repayments may be made electronically online at
https://dwd.wisconsin.gov/epayment/
if you have a checking
account. Please have your PIN available as you will need it to enter it into the electronic payment system.
I AGREE TO REPAY (check one):
1. Initial Payment- In one cash payment in the amount of $
.
2. Monthly Payments - In monthly payments of $
. I understand that if I am currently receiving or if I
receive FoodShare benefits in the future, any outstanding amount may be collected by reducing my FoodShare benefits.
3. Benefit Reduction - By reducing my current monthly FoodShare benefits by $
. I understand that if my
FoodShare benefits are terminated, any outstanding amount owed must be collected.
4. Voluntary Payments – Of $
FoodShare benefits, in addition to the minimum monthly payment
above.
Participant’s Signature
Date Signed
7CFR 273.18
RETAIN COMPLETED FORM IN CASE RECORD
RESET FORM